DSA 1: Atypical Chest Pain, Dysphagia, Odynophagia

Question 1

What are the sxs, dx and tx for pill-induced esophagitis

Answer 1

severe retrosternal chest pain, odynophagia & dysphagia - several hr after taking pill, may occur suddenly and persist for days;

some pt (esp elderly) -little pain, present w/ dyphagia

Dx: Med Hx, endoscopy may reveal one or more discrete ulcers (shallow or deep)

Tx: eliminate offending agent –> heals quickly; drink 4 oz water with pills

Question 2

What is the definition, etiology and causes of diffuse esophageal spasm

Answer 2

multiple spastic contractions of circular M in the esophagus

• fxnal imbalance btn excitatory & inhibitory post-ganglionic paths
• disrupting the coordinated components of peristalsis - uncoordinated esophageal contraction (long duration & recurrent)

barium swallow shows : corkscrew esophagus (MC) or rosary bead esophagus

causes = 1- idiopathic, 2- due to GERD, emotional stress, diabetes, alcoholism, neuropathy, radiation therapy, ischemia or collagen vascular dz

Question 3

What is the treatment for PUD?

Answer 3

acid suppression: PPI, H2 blocker PO or IV if acute GI bleed

eradicate H. pylori

stop smoking

discontinue NSAIDs, endoscopic intervention (if active bleed)

surgery for complications

GU ONLY: exclude malignancy- EGD w/ repeat Bx of ulcer

Question 4

Atypical Chest Pain DDx

Answer 4

MI, aortic dissection, pul embolism (life-threatening)

Esophageal Perforation (life-threatening)

PUD

Nutcracker esophagus

Diffuse esophageal spasm

GERD

Food bolus impaction/obstruction

Question 5

what is the presentation, diagnostic tests and treatment for esophageal perforation

Answer 5

• distress upon presentation
• pleuritic/retrosternal chest pain;

pneuomediastinum or subQ emphysema (snap, crackle, pop when push on chest)

Dx test: CXR or CT w/ contrast (see air in mediastinum/subQ emphysema)

Tx: stabilize, NPO, paraenteral ABx, surgery, endoscopic stenting

Question 6

What are the hx and sxs in pts w/ eosiniphilic esophagitis

(compare & contrast adults & children)

Answer 6

Hx: allergies or atrophic conditions (>50% pt) -stimulate inflam; Hx of food bolus impaction, long hx of dysphagia of solid foods

M>F

Both: eosinphilia, dysphagia

adults: pyrosis, poor medication response, regurg undigested food
kids: vomit, difficulty feeding, failure to thrive

Question 7

how do you Dx and Tx GERD

Answer 7

Dx:

• clinically based on sxs, hx, PE
• consider ambulatory 24-48 hr esophageal pH recording & impendance testing
• CBC, H. Pylori testing
• EGD or ABD imaging if alarming features, > 60 yo, persistent, sxs despite Tx

Tx:

1. empiric (if no alarming features) - try acid suppression (PPI –> H2 blocker) & lifestyle modifications
2. surgery - (symptomatic hiatal hernia)
3. H. pylori eradication if indicated

Question 8

How do you treat esophageal strictures

Answer 8

dilation at the time of EGD - some require intermittent dilation

long term PPI to decrease reoccurence

endoscopic injection of steriods into refractory strictures

Question 9

What is the etiology, Dx and Tx for Zenker Diverticulum

Answer 9

(structural oropharyngeal dysphagia)

etiology:

• structural prob: false diverticula involves herniation of mucosa & submucosa thru the M. layer of the esophagus posteriorly btn the cricopharyngeus M & the inferior pharygneal constrictor Ms (at phayngeoesophageal jxn)
• loss of UES elastivity
• occurs in killian’s triangle: natural weakness proximal to the cricopharyngeus

Dx: video esophagography or barium swallow (do these before EGD to prevent perforation!)

Tx: Surgery- upper mytomy or surgical diverticulectomy

Question 10

how do you prevent pill-induced esophagitis

Answer 10

take pill w/ 4 oz of water & remain upright for 30 mins after

dont give known offending agents to pts w/ esophageal dysmotlity, dysphagia or strictures

Question 11

what are symptoms that present w/ pul embolism

Answer 11

hypercoag state - recent travel or surgery

sudden onset, pleuritic chest pain, SOB

hypoxia, hemodynapic collapse

increase RR & HR

Wells criteria

Question 12

Which disorder is a motility disorder, presents with esophageal dysphagia when accompanied by weak peristalisis & stomach acid reflux due to the LES?

Answer 12

GERD

Question 13

what acute and long term complications of caustic esophageal injury

Answer 13

Acute: perforation (pneumonitis, mediastinitis, peritonitis); bleeding; esophageal-tracheal fistulas

long-term - esophageal stricture (70%) - require recurrent dilations

risk of esophageal SCC 2-3% - endoscopic surveillance 15-20 yrs after ingestion

Question 14

What are atypical sxs of GERD

which symptoms are alarming enough to perform an endoscopy, obtain dirested radiographic Abd imaging, or surgical evaluation?

Answer 14

atypical: asthma, chronic cough, hoarseness, laryngitis, aspiration pneumonitis, chronic bronhcitis, sleep apnea, dental caries, halitosis and hiccups

Alarming features:

• unexplained wt loss
• persistent vomitting –> dehydration
• constant/severe pain
• dysphagia/odynophagia
• palpable mass/adenopathy
• hematemesis
• melena
  
  • anemia (Fe deficiency) –> Occult bleeding

Question 15

describe the difference btn sliding hiatal hernia & paraesophageal hernia

Answer 15

sliding: herniation of stomach into mediastinum thru esophageal hiatus –> bc increase intra-abd pressure from obesity, pregnancy & hereditary (affected pts may have GERD)

paraesophageal hernia: herniation into the mediastinum includes: visceral structure other than gastric cardia & most commonly the colon (can lead to an upside-down stomach, gastric volvulus, strangulation of the stomach) (pictures)

Question 16

What are risk factors and PE findings for GERD

Answer 16

risk factors:

1. increased abd girth/obesity,
2. pregnancy,
3. hiatal hernia- barium swallow

PE: possibly normal, epigastric pain, dental carries, hoarseness

Question 17

What are diagnostic characterisitics of achalasia

Answer 17

peripheral blood smear ; trypanosoma cruzi parasite (if chagas)

barium esophagram - bird beak distal esophagus - esophageal dilation, loss of esophageal peristalsis, poor esophageal emptying

EGD- always performed to evaluate distal esophagus & GE jxn to exclude distal stricture or submucosal infiltrating carcinoma; Bx = loss of ganglion cells w/i esophageal myenetric plexus

esophgeal manometry.- confirm Dx - complete absence of normal peristalsis & incomplete LES relaxation w/ swallowing

CXR- air-fluid level in enlarged, fluid filled esophagus

Question 18

If a white, 55 yo male presents to your office w/ long history of GERD symptoms (heartburn & regurg), what are you concerned about

Answer 18

1. Barretts esophagus -doesn’t have specific sxs, most asym & only sxs present related to long term GERD
2. Adenocarcinoma: RF = chronic GERD, hiatal hernia, obesity, white, male > 50 yo

PE: nothing specific

Question 19

What are lifestyle modifications to suggest for pts w/ GERD

Answer 19

decrease alc & caffeine

small low fat meals

incline bed

assess psychosocial

reduce weight

avoid large meals, smoking, alc/caffiene, chocolate, fatty food, citrus juices & NSAIDS

Question 20

how do you test and treat aortic dissection

Answer 20

test: CXR widened mediastinum

CT w/ contrast = definitive!

Tx: surgery/ BP management

Question 21

What is Hamman’s sign

Answer 21

PE

auscultation - crunching, rasping sound, synchronous w/ heartbeat

heard over precordium during systole (esp in L lateral decubitus position) - maybe w/ muffled heart sound

(esophageal perforation &/or pneumomediastinum/subQ emphysema => differentiate btn Lung and GI problem by pressence of dyspnea)

Question 22

how do you diagnose and treat CMV-infectious esophagitis

Answer 22

endoscopy- one or more large, shallow, superficial ulcerations (may be infected in colon and retina too)

Tx: if pt w/ HIV - immune restoration w/ ART

Question 23

What are characterisitcs of Chagas Dz

Answer 23

esophageal dysfxn that is indistinguishable from idiopathic achalasia;

pts from endemic regions (mexico, central & south america);

by the bite of reduviid (kissing) bug transmits protozon, trypanosoma cruzi;

chronic phase of dz yrs after infxn - results from destruction of autonomic gangion cells throughout the body

Question 24

how do you test and treat pul embolism

Answer 24

ECG: sinus tach (MC)** or **S1Q3T3

CTA: best but may not for best option of pt (pregnant, renal failure)

VQ scan, LE venous doppler US

Tx: stabilize, anticoag (aspirin unless contraindicated!)

Question 25

What are the Hx/PE findings for esophageal web & how do you Dx

Answer 25

(strucutal oropharyngeal dysphagia) dysphagia with _solids_: **if proximal = oropharyngeal** (if mid- esophageal) can be asymp or **intermittent & not progressive** if circumferential - looks similar to schatzki ring (but these are distal & webs are mid-proximal) Dx: **barium swallow (esophagram)**

Question 26

What are RF and Complications for Pill-induced esophagitis

Answer 26

RF: _medications_ (NSAIDs, KCl, Alendronate & risedronate (for osteoporosis), iron, ABx) **most likely occur bc swallow pill w/o water or while supine** (increased risk in hospitalized/bed-bound pts) complications: severe esophagitis w/ stricture, hemorrhage, perforation

Question 27

What is the definition, etiology and association nutcracker esophagus

Answer 27

**hypertensive** peristalsis -swallowing contractions are _too powerful_ _greater amplitude & duration but **normal coordinated**_ contraction associated w/ increased freq of depression, anxiety & somatization

Question 28

what is the atypical presentation of MI how do you test & treat

Answer 28

_dyspepsia_ _epigastric pain_ distressed, diaphoretic, pale impending doom murmur test: ECG, tropnoin CXR treat: stabilize, aspirin, PCI or CABG

Question 29

What is the etiology for Achalasia

Answer 29

(**motlity esophageal** disorder) --\> solids **&** liquids (**progressive**) increased incidence w/ age - _propulsion problem_ - loss of peristalsis (distal 2/3) & **failure** _of deglutitive LES_ - denervation of esophagus from **loss of NO producing inhibitory neurons (ganglion cells) in the _myenteric plexus_**

Question 30

what are risk factors for infectious esophagitis?

Answer 30

**Immunocompromised pt** - increase risk of opportunistic infxn increased risk for Cadida infxn - **uncontrolled diabetes, treated w/ systemic corticosteroids, radiation therapy, systemic Abx** HSV- **can affect normal hosts**

Question 31

Presentation & DDx for oropharyngal dysphagia?

Answer 31

difficulty **initiating** swallowing food sticks at level of suprasternal noth possible nasopharyngeal regurgitation or aspiration solids only (structural cause) OR solids & liquids

Question 32

What is the etiology & Tx for esophageal webs

Answer 32

(structural oropharyngeal dysphagia) _Etiology:_ * **stuctural prob** --\> thin, diaphragm-like membrane of squamous mucosa; _proximal or mid esophagus_ * congenital * acquired: _eosinophilc esophagitis_ or rarely **Plummer vinson syndrome** _Tx:_ **dilatation** (bougie dilator) or small endoscopic electrosurgical incision _long-term PPI_ if persistent heartburn or need repeat dilations

Question 33

What are causes of the esophageal perforation (life-threatening chest pain due to GI)

Answer 33

**_Spontaneous_**: forceful retching/vomit; Hx of alc use; _Boerhaave's - transmural rupture at G-E jxn_ **_Iatrogenic:_** trauma, medical cause - NGT placement of endoscopy

Question 34

What is the presentation of a pt w/ esophageal strictures

Answer 34

(structural esophageal dysphagia) gradual (mon-years), _progressive: **but reflex/heartburn LESSEN/improve** bc the stricture act as a barrier to reflux (dysphagia will continue to worsen)_ 1st solids --\> then both

Question 35

What is the presentation and DDx for esophageal dysphagia

Answer 35

food sticks in the **mid-lower sternal area** possible regurg, aspiration or odynophagia solids only OR solids & liquids

Question 36

what are similarities for nutcracker esophagus and diffuse esophageal spasm

Answer 36

both = esophageal dysmotility both symptoms: _dysphagia_ to solid & liquids; **atypical chest pain** dysphagia: intermittent, not progressive Dx: **Manometry & EGD** to exclude mechanical & inflam leasons (_diffuse esophageal spasm - use barium swallow_) Tx: Nitrates, Ca2+ antagonists, treat concomitant mental healthy

Question 37

what are diagnostics for PUD

Answer 37

EGD w/ Bx (_exclude malignancy in GU)_ X-ray/CT/MRI if suspect complications (perforation, penetration, obstruction) CBC (anemia) & Chemistry (UGIB = increased BUN) _Nasogastic lavage - but if neg DOES NOT exlude active bleeding from DU_ **_detecting H.pylori - stop PPI 14 days before fecal and breath test_** (bc risk of false neg) * **fecal Ag test:** sensitive, specific, inexpensive (_confirm eradication)_ * IgA _Ab_ in serum (not _good for confirming eradication_ bc present for weeks after) * **_Urea Breath Test_**: confirm readication * _Upper endoscopy w/ gastric Bx_ -_warthin-starry's silver stain and immunohistochemistry stain_ & histology/rapid urease test of antrum (Clofazimine)

Question 38

what is globus pharyngeus

Answer 38

sensation of a lump lodges in the throat BUT swallowing unaffected (unlike dysphagia which is problem w/ swallowing)

Question 39

What is the presentation for rheumatologic esophageal dysphagia

Answer 39

Question 40

What is the presentation of a pt w/ achalasia

Answer 40

gradual, **_progressive**_ dysphagia w/ solids _**&_** liquids regurg undigested foods (diff from zenker diverticulum bc it nocturnal regurg) substernal discomfort/fullness (ma be associated w/ meals, may last several hrs) adaptive maneuvers = _eat slowly, lift neck or through shoulders back to enhance esophageal emptying_ **wt loss**

Question 41

What is it called when a pt presents angular chelitis, glossitis, koilonychia and weakness/fatgiue what else will they present with

Answer 41

**Plummer Vinson syndrome** (MC middle age women) iron def anemia (weakness & fatigue) _symptomatic proximal esophageal webs_

Question 42

How do you diagnose and treat herpes simplex esophagitis

Answer 42

**endoscopy- multiple small, deep ulcers** (may see oral ulcers too) Tx: symptomatically if immune compromised tx w/ oral acyclovir

Question 43

what are PE findings of Achalasia & how do you treat?

Answer 43

PE: idiopathic - nothing specific, _see wt. loss_ & 2ndary - swelling, **_Romana sign-_** _unilateral painless swelling around eye (periorbital)_, arryhthmia, fever Tx: 1. reduce LES pressure - **nitrates & Ca2+ channel blockers;** botox 2. pneumatic balloon dilation - risk of perforation/bleeding 3. surgery (myotomy) - up to 30% have GERD after; all pts given PPI qd 4. w/o Tx - esophagus becomes dilated - _sigmoid esophagus_

Question 44

what is due to structural esophgeal dysphagia w/ smooth, circumferential, thin mucosal structures, _distal_ & is associated w _hiatal hernias_ What is the Hx, Dx, and Tx for this?

Answer 44

=Esophageal ring aka _Schatzki ring_ Hx: **intermittent, NOT progressive dysphagia for solid foods;** reflux sxs common; **"steakhouse syndrome"** = large poorly chewed bolus cause _food impaction_ (pass on own w/ drink, after regurg, if impacted --\> extracted via endoscope Dx: **barium swallow** Tx: **Dilation (bougie dilator);** small endoscopic electro surgical incision; if persistent reflux sxs - _long term PPI_

Question 45

Differentiate primary, secondary and pseudo-achalasia

Answer 45

_1- idiopathic_ - _loss of ganglion cells w/i_ the esophageal _myentric plexis_ **2ndary**- MC: **Chagas dz** other 2ndary causes = lymphoma, Ca, chronic idiopathic intestinal pseudoobstruction, ischemia, neurotropic virus, drugs, toxins, radiatino therapy, postvagotomy _Pseudoachalasia = primary of metastatic tumors invade the GE jxn_ - resemble achalasia

Question 46

how do you tx caustic esophageal injury

Answer 46

hospitalize - icu **_Nasogastric lavage**_ & oral antidotes _**SHOULD NOT_** be used bc re-exposure to corrosive agent inital treatment - supportive - NPO, IVF, IV PPI and analgesics; monitor for signs of deterioation --\> emergent surgery; NO corticosteroids or ABx **Laryngoscopy-** pts w/ resp distress - access for need of _tracheostomy_ **EGD**- w/i 12-24 hrs to assess extent of injury (no injury - psychiatric referral) severe injury -deep/circumferential ulcers/necrosis (black discoloration) ==\> _high risk up to 65% of acute complications_

Question 47

What is your DDx for mechanical obstruction esophageal dysphagia

Answer 47

esophageal web (plummer-vinson syndrome) hiatal hernia GERD- **unresponsive reflux dz w/ esophagitis** (pts have dyphagia & **_odynophagia)_** GERD complications: _esophageal stricture & barret esophagus_

Question 48

What are typical sxs for GERD

Answer 48

typical: * 30-60 mins after eating, associated w/ spicy, alc, caffiene * symptoms upon reclining * epigastric abd pain/abd fullness * N/V * _intermittent, not progressive, solid & liquid_ esophageal dysphagia * **waterbrash-** bad taste in mouth * "heartburn"/indigestion

Question 49

what is the prevelance, RF, Dx and Tx for esophageal adenocarcinoma

Answer 49

**white, male** RF: _GERD-BE --\>_ dysplasia --\> adenoCa Dx: EGD w/ Bx (**distal 1/3) - see squamous to columnar** Tx: **endoscopic therapy (ablation)**

Question 50

if a pt presents with rheumatologic oropharyngal dysphagia, what syndrome do you think of?? explain etiology, Hx, PE, Dx, Tx, Complications

Answer 50

Question 51

what are complications of PUD

Answer 51

_bleeding, obstruction (from edema), perforation, penetration into pancreas --\> pancreatitis_ ulcer along _posterior wall of duodenum or stomach_ --\> could _perforate into contiguous structures_ (pancreas, liver, biliary tree)

Question 52

What complications may occur with GERD

Answer 52

**_laryngopharyngeal reflux (LPR)_**- asthma like sxs, acid reflux into larynx, chronic cough & hoarseness esophagitis stricture **Barrett's esophagus --\> _adenocarcinoma_**

Question 53

besides GERD, what is the cause of esophagitis due to refractory reflux

Answer 53

gastrinoma w/ gastic acid hypersecretion (zollinger ellison syndome) pill-induced esophagitis resistance to PPI medical non-compliance

Question 54

what are RF and sxs of caustic esophageal injury how do you diagnosis this?

Answer 54

ingestion fo liquid/crystalline alkali or acid RF = kid - accidental or suicidal- deliberate almost immediately - **severe burn & varying degress of chest pain, gagging, dysphagia & drooling** (also see dyspnea, hematemesis, oropharyngeal lesions) aspiration in stridor & wheezing Dx: inital exam - circulatory status & airway patency and oropharyngeal mucosa, **includig laryngoscopy** **chest & abd radiogrphy-** look for pneumonitis or free perforation

Question 55

what is the Tx and complications of eosinophilic esophagitis

Answer 55

tx: PPI, swallow inhaled glucocorticoids, allergist referral, eliminate common food allergy, _esophageal dilation_ effective in relieving dysphagia in pts w/ fibrostenosis - **risk of deep, esophegeal mural laceration or perforation** complications: esophageal stricture, narrow-caliber esophagus, **food impaction, esophageal perforation**

Question 56

What are symptoms of food bolus impaction/obstruction

Answer 56

**hypersalivation: inability to swallow liquids (including saliva) ==\> drooling, frothing/foaming at the mouth** severe chest pain/pressure dysphagia/odynophagia sensation of choking neck/throat pain retching & emesis

Question 57

what are the Dx processes used to test oropharyngeal dysphagia vs esophageal dysphagia

Answer 57

_oropharyngeal:_ video-flouroscopy of swallowing _esophageal:_ * _mechanical cause:_ barium swallow or esophageogastroscopy w/ Bx * _motor cause:_​ barium swallow or esophageal motlity study (manometry)

Question 58

What is the etiology, PE and Dx for esophageal strictures

Answer 58

(**structural** esophageal dysphagia) etiology: MC structural prob at _GE jxn_; presents in 5% of ppl w/ esophagitis MCC: **_Peptic secondary to GERD_** _but can also occur btn of eosinophilic esophagtitis_ PE: nothing specific Dx: **EGD w/ Bx** _mandatory in all cases to differentiate peptic stricture from stricture by esophageal carcinoma!_ ; Barium swallow (maybe useful)

Question 59

what are the types of esophagitis & when do you add it to your DDx

Answer 59

esophageal dysphagia & **odynophagia** (add to DDx w/ this symp) mainly w/ **solids** types: 1. _pill_ 2. _infectious_ 3. _eosinophilic_ 4. _caustic_

Question 60

what is the management and Tx recommended for Barrets esophagus (BE)

Answer 60

management: **surveillance endoscopy** - every 3-5 yr for pts w/ BE or _high risk of adenocarcinoma_ (long term, qd or bid PPI _**may** reduce risk of cancer)_ _Tx:_ 1. **_PPI_**- long term, qd/bid to control reflux symptoms - \*DO NOT cause regression of BE\* 2. **_endoscopic ablation:_** in pts w/ _high grade dysplasia or intramucosal adenocarcinoma (DO NOT surgically resect in pt w/ Ca)_ 3. surgery resection (esophagectomy --\> high morbidity/mortality) = _NOT recommended_

Question 61

what are risk factors and ways to manage _food bolus impaction/obstruction_

Answer 61

RF: * schatzki ring, * peptic stricture, * webs, * esophagitis, * achalasia, * CA management: pass spontaneously, endoscopically, surgery

Question 62

What is diagnostic for eosinophilic esophagitis

Answer 62

EGD - loss of vascular markings (edema) longitudinally oriented furrows & punctate exudate **multiple circular esophageal rings creating a corrugated appearance -**"feline esophagus" or "tracheal esophagus" Bx: squamous epithelial **eosinophil-predom** inflam (15-20 eosinophil per high power field)

Question 63

What is the most common type of esophageal Ca in the world? population, RF, sxs, Dx, Tx?

Answer 63

SCC of Esophagus African american, male, \>50 yo RF: **heavy smoker/alc use** (synergistic); esophageal disorders (_achalasia, HPV, plummer vinson, tylosis);_ **caustic** chemical/termal injury (lye ingestion, hot drinks, radiation 5-10 yrs ago) Sxs: **_Progressive_** _dysphagia; **wt. loss**_; _anorexia, bleeding, hoarseness, cough_ Dx: EGD w/ Bx- esp check **middle 1/3** (50%) Tx: **surgery** (esophagetcomy)

Question 64

What are life-threatening causes for atypical chest pain that are NOT-GI related

Answer 64

MI aortic dissection pul embolism

Question 65

How do you diagnose and treat candidal esophagitis

Answer 65

**endoscopy - diffuse, linear, yellow-white plaques afherent to mucosa** Tx: systemic (fluconazole)

Question 66

what are risk factors for atypical MI presentation

Answer 66

elderly female DM

Question 67

What is the etiology for PUD

Answer 67

aggressive factors overwhelm defensive factors involved in mucosal resistance & from effects of _H. pylori_ MC: _duodenal bulb (DU) & stomach (GU)_ DU- 30-55 yo GU- 55-70 yo

Question 68

what is the atypical presentation for aortic dissection

Answer 68

sudden onset- tearing/ripping chest pain may radiate to neck syncope, altered mental status CVA sxs: hemiparesis, extremity parethesia impending doom high/low BP asymmetrical pulse

Question 69

What are important Hx/PE findings for PUD

Answer 69

Sxs w/ periodicity (several weeks w/ intervals of mon-yrs are pain-free) * epigastic pain - **_gnawing, dull, aching or hunger-like_** * **_atypical chest pain_** * _**GIB**: coffee ground emesis, hematemesis, melena, hematochezia_ exacerbating factors: **anxiety/stress, coffee, alc (w/o cirrhosis)** PE: normal in uncompleted PUD; **_mild, localized epigastric tenderness to deep palpation,_** hyperactive bowel sounds

Question 70

What is the etiology and Dx of Barretts esophagus?

Answer 70

etiology: * **specialized intestinal (metaplastic) columnar metaplasia-** _replaces the normal sqamous mucosa of distal esophagus_ * proximal displacement of _squamocolumnar jxn_ * **_--\> esophageal adenocarcinoma_** * RF: complication of _GERD or truncal obesity_ * Greatest risk : **_obese, white, male, \>50 yo who smokes_** Dx: **screening EGD** considered case by case, **esp for ppl with RFs** **EGD w/ Bx**: _orange gastric type epithelium extends up from stomach to distal 1/3 esophagus in tongue-like or circumferential fashion ;_ **Bx = goblet & columnar cells**

Question 71

what is the Hx & PE findings of Zenker Diverticulum

Answer 71

(structural **oropharyngeal** dysphagia) -affect upper esophagus w/ vague sxs at first (_cough or throat discomfort)_ As diverticulum enlarges it retains food (_progressive)_ --\> **halitosis, spontaneou regrug, nocturnal choking, gurgling in the throat, protrusion in the neck** _voice change, wt loss, aspiration --\> pneumonia/lung absess_ gradual/insidious _MC: older males_